Your Paramedic crew is called to the home of a 58 year old male, “possible heart”

Upon arrival to the home, you are greeted by the gentleman’s wife, who directs you to your patient. You find him sitting in a chair in the living room, appearing concerned, but in no serious distress.

He tells you that while he was excercising on his treadmill, he experienced sudden onset of chest discomfort in the middle of his chest, described only as “pain”. He also tells you that is right arm started hurting at the same time, with some “pins and needles”. Almost as an afterthought, he tells you that he immediately stopped exercising when the pain started, but continued to have a “cold sweat” and became nauseous. He adds that he feels a bit better now.

His wife tells you that normally he would have waited to see how he felt, but they had just attended the funeral of a friend the previous day who died of sudden cardiac arrest, and that was fresh on their minds so they called 911 immediately.

He denies any shortness of breath or lightheadedness. No previous episodes like this, and his history is significant only for hypertension.

Vitals are as follows:

BP: 150/98

HR: 74

RR: 20, Lungs clear, SpO2 98% RA

Skin: now warm and moist, and a little pale

Here are the 12 leads, standard and right sided:

What do you think?

Would you activate the cath lab?

How would you treat this patient on the way to the hospital, which is 30 minutes away?

9 Comments

The T waves in III and aVF are hyperacute, plus there is STD with flipped T waves in I and aVL – this appears to be RCA occlusion. The 15-lead shows what looks like some STE in V4R. Based on his clinical presentation, I would activate the cath lab. En route (assuming there is RV involvement), fluids to maintain perfusion, no NTG, and little “bumps” of fentanyl as needed for pain.

Agree with Stephen except about V4R. I do think that V8 and V9 confirm what you already know: that there is also posterior MI, as clearly seen in V2-V4. What’s more is that this is in the context of an intraventricular conduction defect that resembles LBBB. If you want to apply Sgarbossa criteria, this one meets them with the concordant STD in V3. But the hyperacute T-waves are sufficient to activate.

Additionally, I would say that it is advantageous to place the defibrillation pads ahead of any potential arrhythmias. I was once yelled at by a cath lab nurse for failing to do that on a STEMI transfer. Despite her lack of tact, I decided to follow her advice. Came in handy when a patient coded on me in the middle of nowhere. There was no ectopy leading up to the VT/VF arrest.

Great point. I’ve seen a couple of cases where a STEMI patient’s only PVC (over the course of an hour or more) was the one that put them into VF. Now, the pads go on any time I’m calling a STEMI alert.

I would give some morphine, NTG, and aspirin. Here, in Latvia, no clopidogrel and heparin is requested if there is no evidence of STE. Clopidogrel is now replaced with ticagrelor. On the scene would like to see some previous ECG’s to compare. There is LBBB, difficult to interpret the ECG, may be old changes. High sensitivity tropining needed.

I’m not sure if this will make any difference with the treatments but im just trying to interpret it first because if there is a LBBB then it does not meat Sgarbossa criteria and if it is A-Flutter that could explain the hyper acute T’s in 3 and AVF and what may look like depressions in V1-V3.

Regardless, I think the Pt. needs to go to the cath lab because of the positive stress test that he did for us.

@ Eli — I don’t see AFlutter. That is, I see no indication of regular atrial activity at a rate consistent with AFlutter. Instead, the rhythm is irregularly irregular without P waves = AFib at a controlled ventricular response. In my opinion, one doesn’t need Sgarbossa criteria here to activate the cath lab. So, yes the QRS is wide with a pattern that resembles LBBB — with small q waves (that shouldn’t be there) in V5,V6 — and with primary ST-T wave changes in the form of clearly hyperacute ST-T waves in leads III and aVF. It’s a bit hard to recognize the abnormal ST-T waves in leads I and aVL (because there normally is some ST-T depression in these leads with LBBB) — but NOT as deeply negative as seen here (with the ST-T wave in lead aVL being the “mirror-image” of the ST elevation in lead III). There are also primary ST-T wave changes in several chest leads. Specifically, you should NOT see ST-T depression in V2-V4 as we do here — with these changes really being consistent with acute infero-postero STEMI. These “qualitative” ST-T wave changes are diagnostic of an acute event (and justify activation), without need to invoke Sgarbossa criteria in my opinion — 🙂

Ken Grauer58 Year Old Male, Workout Worry@ Eli — I don’t see AFlutter. That is, I see no indication of regular atrial activity at a rate consistent with AFlutter. Instead, the rhythm is irregularly irregular without P waves = AFib at a controlled ventricular response. In my opinion, one doesn’t need Sgarbossa criteria here to activate the cath lab. So, yes the…
2018-09-13 02:09:24

Vince DiGiulioIs epinephrine harmful in cardiogenic shock?Sorry about that; I copied the quote from the article and my browser automatically changed the "μ" to an "m". Thanks for noticing, and thanks for pointing it out in the most passive-aggressive manner possible.
2018-09-12 16:45:26

Ken Grauer, MDElectrocardiographically Silent High Lateral STEMI EquivalentHi Tom. This is a great case — so NICE that you posted it for others to learned from. But as I commented several times when you sent this case around to our group — the T waves in V2,V3 are disproportionately peaked and transition occurs early (between V1-to-V2) — so the chest leads are NOT…
2018-08-14 08:38:03

Eli58 Year Old Male, Workout WorryAnybody else see the possibility of a LBBB or A-Flutter? I'm not sure if this will make any difference with the treatments but im just trying to interpret it first because if there is a LBBB then it does not meat Sgarbossa criteria and if it is A-Flutter that could explain the hyper acute T's…
2018-07-20 21:29:21